Shoulder problem

[Owen Harris]

Thanks for your help.
My patient is a middle aged woman who was referred with a ? frozen shoulder. She presented with a 9/12 hx of shoulder pain. Her pain was of incidious onset and was currently ISQ. She has recently had a steriod injection from her doctor which has not hanged her symptoms.
Her main Aggs are any movement towards end of range and lying on her affected side. Her symptoms settle quickly.
Her pain follows a mechanical pattern throught the day.
She is active and has no psychosocial issues.
On obj ax her active abd was restricted at 80' (ltd by pain) and 110' was available but again pain stopped me going further. External rotation was painful but not particularlly restricted. Internal rot was 1/2 rom and painful, flex was restricted by pain at 110' and painful.
Her MM strength seemed fine.
I cleared the Neck, thx spine and her neurodymnamics were unremarkable. Special tests for impingement wee negative and palpation did not present any answers..
ROM was not increased by off-loading neural structures.

Basically i am stumped
i do not think it is a capsulitis but i wonder if i have missed something.

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[Physiobase]

Her main Aggs are any movement towards end of range and lying on her affected side.

Thus she does not have a frozen shoulder, that is the first point of clarification.

Think about the mechanics at the 70-120 degree mark. The AC joint comes to mind, as does subacromial impingment and tendinosis. Where exactly did the Dr place the steriod?

It may well be a tendinosis with subsequent rotator cuff tear. An MRI or diagnostic ultrasound would be of assistance in the diagnosis. It seems you are checking all the right places but if this issue has been there for 9/12 she might have quite a few secondary symptoms that are over-lying the main issue. Try releasing under the scapula (subscapularis), mobing the AC joint and SC joints just short of the painful range and perhaps tape to inhibit the upper trapezius. Then send away for 24 hours and get her back to recheck. Any increase in range will be progress.


Looking forward to hearing more on this one

[Ehuner]

Hi there,

It does sound like a tough case and it's always tough to judge a gleno-humeral limitation when you can't appreciate an end-feel because the patient doesn't let you or is unable to let you due to pain. It doesn't sound like a 'frozen shoulder' if the external rotation is full but make sure to check external rotation range both in neutral and abduction ensuring the scapula is stationary. Be sure to test horizontal flexion isolating the gleno-humeral motion only as there may be a posterior capsule restriction as it sounds like internal rotation is limited. If you haven't already, check the resting position of the humeral head in the glenoid fossa e.g. is it too anterior, and whether it translates excessively during internal rotation/external rotation i.e. it should stay centered except for mild end range movements and should not translate (nor the scapula with resisted testing). Be sure to make sure the scapula isn't depressed or downwardly rotated at rest and that it moves sufficiently with arm elevation although it sounds like her active movements are too limited to make a good judgement on that one. Hope that helps.

Cheers,

E Huner PT, FCAMT